Federal and State Policy
As the largest US healthcare payer, the federal government plays a dominant role in shaping the healthcare marketplace, while states take center stage when it comes to developing novel policy approaches. Our experts track, interpret, and model policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
State Medicaid Waivers for SUDs Present Opportunities for Stakeholder Engagement
1115 Waivers approved by CMS allow state Medicaid programs to better address substance use disorders among beneficiaries.
Evolving COVID-19 Impacts on Health Insurance Enrollment
On May 13, Avalere experts discussed key issues and considerations for the healthcare industry as millions of Americans shift in and out of new sources of coverage due to COVID-19.
Manufacturers Must Navigate Evolving State Approaches to Medicaid Drug Benefit Management
As control of the Medicaid drug benefit continues to shift from managed care organizations to states, manufacturers should understand unique benefit dynamics in each state, particularly as Medicaid enrollment is likely to increase amid the COVID-19 pandemic.
Provider Impact of COVID-19 Recession and Coverage Trends
A potential recession due to job losses and business closings as a result of COVID-19 will cause shifts in the payer mix and, ultimately, revenue dynamics for physician practices.
COVID-19 Relief Funding for Healthcare Providers
Avalere analysis of the distribution of provider relief funds indicates geographical concentration related to the number of reported COVID-19 cases.
10 Drivers Complicate the Medicaid Outlook Amid the COVID-19 Pandemic
State Medicaid programs face a series of near- and long-term challenges amid the COVID-19 pandemic due to enrollment growth and financial pressures. Stakeholders should evaluate key drivers shaping the state-by-state Medicaid outlook.
Emergency State Licensing Flexibilities May Improve Provider Access
Recent regulatory changes have eased restrictions for providers delivering care across state lines during the COVID-19 public health emergency. However, state and federal cooperation on extended licensure expansion would help address long-term provider access issues.
Webinar: Evolving COVID-19 Impacts on Health Insurance Enrollment
Avalere experts discussed the key issues and considerations for the healthcare industry as millions of Americans shift in and out of new sources of coverage.
Patients with Undermanaged RA Have Higher Medicare Costs than Other RA Patients
Avalere analysis finds that Medicare fee-for-service (FFS) patients with an RA diagnosis and conditions associated with undermanaged disease have 121% higher medical costs than other RA patients. Part D costs were 30% higher for those with undermanaged disease than for other RA patients.
Interview: E8 – Get the Facts on COVID-19: The Pharmacy Business
Tune into the eighth episode of our series of podcasts that focuses on COVID-19. In episode 8, Avalere experts from the Policy practice discuss the impact of COVID-19 pandemic on retail pharmacy and pharmacists.
COVID-19 Poses New Challenges in the Evolving Kidney Care Landscape
The kidney care payment and delivery landscape was poised for change in 2020 due to existing policies and market trends. Given the specific risk COVID-19 poses to these patients, the pandemic is creating new challenges and potentially accelerating existing trends in the kidney care space.
Treatment Disruption due to COVID-19 Poses Challenges to Practices in OCM
Oncology practices with a substantial proportion of Oncology Care Model (OCM) episodes in areas with high numbers of COVID-19 cases—such as Connecticut, Louisiana, Massachusetts, New Jersey, New York, and Pennsylvania—may face new challenges in containing total expenditure below target amounts.
Biden’s Medicare at 60 Proposal Could Cover 23M Under Medicare
Avalere analysis finds that former Vice President Joe Biden’s proposal to lower the Medicare eligibility age from 65 to 60 could increase access to Medicare coverage for an additional 23 million individuals.
Two-Thirds of Seniors Have High-Risk Conditions in Counties with the Most COVID-19 Cases
Avalere analysis finds that in the top 25 US counties with highest number of COVID-19 diagnoses, two-thirds of Medicare beneficiaries have 1 or more high-risk medical conditions.
COVID-19 Considerations for Medicare Advantage Plans
The COVID-19 pandemic will have ongoing, market-wide implications as Medicare Advantage (MA) plans contend both with responding to the virus and the disruption to their normal activities.
Medicare Spending on Treatments for Ophthalmic Conditions
Avalere analysis finds that new users account for a large share of Medicare spending on opthalmic medications.
State Legislature Suspensions due to COVID-19 Leave Policy Agendas Unfinished
In response to the novel coronavirus (COVID-19) pandemic, a majority of state legislatures have either suspended their ongoing legislative sessions or adjourned sine die, which marks the definitive end of a state’s session, earlier than originally scheduled.
New Federal Rule Could Affect Infusion Site of Care Amid COVID-19 Pandemic
The Centers for Medicare & Medicaid Services (CMS) issued a new Interim Final Rule (IFR) that is intended to allow additional beneficiaries, especially those who are at high-risk, to receive home infusions amid COVID-19 transmission concerns. Specifically, the CMS clarified the definition of “homebound” under the Medicare Home Health Benefit and temporarily suspended enforcement of the National and Local Coverage Determinations (NCD and LCD) related to home infusion services. Uncertainties remain as to how these new flexibilities will be utilized, as well as how these flexibilities could impact treatment outcomes.
Select Part D Plans Have Higher PMPM Spending for LIS in Most Protected Classes
As plans continue to assess the proposed changes to their liability in the Medicare Part D benefit, understanding variations in spending by enrollee can help elucidate how policy changes might affect their spending. This Avalere analysis examines a subset of MA-PD and PDP plans with at least 75% of their enrollment comprising those with LIS. This analysis aims to quantify spending on drugs within the 6 protected classes for low-income subsidy (LIS) and non-LIS beneficiaries in this subset of PDP and MA-PD plans.
Interview: E5 – Get the Facts on COVID-19: The Healthcare Landscape and Policy Debate
Tune into the fifth episode of our series that focuses on COVID-19. In episode 5, Avalere experts from the Policy practice discuss how COVID-19 has impacted the healthcare landscape and policy debate.